Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Saturday, January 25, 2014

Over on Clinical Psychiatry News, I have article up about the survey on "Who are the Mentally Ill?" I talk about how the survey was done and what findings there were, along with a few of my thoughts about those findings. Click Here.

My post on Why Psychiatrists Don't Take Insurance is up on KevinMD. Lots of comments on Shrink Rap, feel free to comment to a broader medical audience over there. Click Here.

Then Clink's stuff:

Over on Clinical Psychiatry News this week, Clink is writing about recreational flotation tanks and their comparison to sensory deprivation. I suggested the Shrink Rappers take a field trip to a Flotation Tank; it could be an extension of our field trips to go on Segway Tours. Clink says you can't fit a Segway in a flotation tank. What a kill joy. Click Here to read her article.

Since involuntary commitment is always a popular topic here on Shrink Rap, I thought I'd steer you to two blog posts. One of our California colleagues, Dr. Reidbord, wrote about the "5150" certification in his state and whether fear of being committed keeps people from seeking care. And a young trainee in the UK, Dr. Langford, looks at forced community (outpatient) treatment on his side of the pond. Oh, some of the research he quotes is from our side as well. Interesting that there is no forced medication for outpatients there.

[Clink Addendum:]

For anybody trying to read our Clinical Psychiatry News columns, I know you get a logon page when you click on the headline. I've got an email in to our editor to see if we can get that fixed. Registration is free, but it's always a pain to click on a link to a logon page. Thank you for your patience.

22
comments:

Anonymous
said...

I will repost what I posted on Dr. Reibord's site. A woman who had been the victim of domestic violence and saw her worst fears come to light regarding her abusive husband murdering her teenage son before committing suicide was involuntarily held against her will for 5 weeks. Fortunately, a judge released her immediately.

Instead of having a psychiatrist like Dr. Reibord, she had one who had police on standby to detain her if she didn't agree to go to a hospital when she arrived for her appointment. And what was supposed to be a 72 hour hold turned into an involuntary stay of 5 weeks.

Anyway, she didn't get the two week period to grieve that the DSM is supposed to provide before labeling someone as mentally ill. Yes, I am being sarcastic.

It's easy to talk about involuntary commitment in a philosophical way, but I think it's important to actually see what goes on.

Here's an example of a doctor in Brisbane who is under an ITO (involuntary treatment order) who records what he considers to be an assault on his body. The drugs are causing him distress and side effects which he documents but no one seems to care about.

AA, per another one of his videos he states years ago his family had him committed because he said they supported the Tamil Tigers. The interesting thing is his opinion, as evidenced by the videos, hasn't changed at all over the years. So, the drugs didn't do a thing to change this belief.

I posted the link because I think it serves as a warning. How can society decide for a person he has to endure side effects like sexual dysfunction, slurred speech, hypersomnia, weight gain, and increased risk of heart disease and diabetes for no perceived benefit?

What is being accomplished in this situation, for this person? Should a patient still be forced to endure side effects even in the face of no benefit? Do they just keep ordering bigger and bigger shots until he's in a coma or he cries uncle, "I no longer believe my family supports the Tamil Tigers?"

Our commenters may not want to hear this, and certainly there are stories of good-intentions-gone-wrong, but these stories tell one side. It's what's wrong with Robert Whitaker's books-- he takes one person's views, without hearing the other side, and presents it as fact. The patient said the medicines caused their kidney failure (and maybe it did), but it's not a medicine that's known to cause kidney failure, and Mr. Whitaker did't review the medical records or have a doctor review them, so the patient says the medicine caused kidney failure, but neglected to mention the years of non-adherence to a diabetic diet, or that big motrin overdose. There just has to be more to the story of the poor mother greeted at an appointment and certified for weeks, than evil psychiatrists. I'm not saying it wasn't wrong, or that perhaps protocol got waylaid for some reason, but the psychiatrist isn't allowed to tell the newspaper what he observed that made him believe the patient was a risk.

@DinahI'm sorry , but it just doesn't matter whether there was more to the story or not. The facts speak for themselves. A psychiatrist decided that she needed involuntary commitment BEFORE she arrived at a scheduled appointment - without bothering to ascertain her mental state? Based on a statement made at some time in the past?

The most interesting part, to my mind, is the fact that a State Superior Court Judge disagreed, basically stating that the reasons given to hold her did not suffice. There was no legally supported reason for an involuntary commitment. That authority, the one that allows psychiatrists to essentially kidnap someone and hold them against their will, is granted by law - and a higher legal authority ruled that the application of that power was improper in this case (which is a nice way of putting it). Yet you still think there's more to it? Perhaps there is, but the additional information merely colors the picture, the details remain the same. A woman was forced against her will, via the police no less, into custody for no valid legal reason, and held for 51/2 weeks. So much for a 72 hour hold. So much for observation. So much for psychiatric treatment. It appears that the psychiatrist failed to understand when a hold is valid, why a hold should be extended, or what rights a patient has. How the hell did this happen?

It happened because involuntary commitment is wrong. It holds the potential for abuse, for error, for just plain arrogance on the part of the 'provider'. It also offers little: what did this woman gain from this ordeal? It would appear to be nothing. What did she lose? Well, 51/2 weeks of her life, her liberty, her autonomy, her ability to choose her associations freely, possibly even her dignity; and I haven't even mentioned the monetary issue. It seems that, although complicit in illegally holding this woman, and of inflicting this indignity, this loss of self upon her, the facility decided to add insult to injury by sending her a bill for their "services". Does this get any more surreal? They were party to her kidnapping, and now are demanding payment for it?

Perhaps now you can see why I hold such a strong opinion regarding involuntary commitment. The potential for harm is significant, even if or when it is applied with good intentions (and we all know what road is paved with those..).

P.S. while the psychiatrist can't "tell the newspaper what he observed that made him believe the patient was a risk", he certainly can, and likely had to, tell the Judge. And the Judge still disagreed. So there's that.

I agree completely with Dinah's comment above. Both comments actually. AA commented both here and on my blog that if I had been the treating psychiatrist, the poor woman wouldn't have been wrongly detained. While I appreciate the vote of confidence, I honestly don't know that. The devil is in the details.

The US legal system is structured with appeals. Decisions made on the street by police are often overturned at the arrestee's arraignment, municipal court decisions by the superior court, and so on. In my state, the 14-day "5250" commitment is often upheld in judicial review, but sometimes overturned. This doesn't mean the overturned ones were a miscarriage of justice — it's how the system is supposed to work.

Since I don't know the details of this woman's commitment, I'm not in a position to say whether it was clinically and legally indicated. She has a right to sue if she believes it wasn't, and if she does, a court will decide. However, I do have an opinion about not receiving a judicial hearing for over 5 weeks. Whatever one feels about involuntary commitment in general, this patient's rights were clearly abrogated when she wasn't granted a judicial review for over a month.

Yes, actually, it does. It says that a Judge - an arbiter of justice and authority on the legality of this detainment - could not find just cause for the detainment. Your statement here suggests that, despite the determination of inappropriatenessregarding this commitment, you still want to find cause for the action; still want to hold to the ability to detain someone; even without just cause; still want to prove the psychiatrist right. Because he couldn't possibly be wrong, just because a judge said so. No, there must be a reason. A reason to interrupt anothers life, to remove them from their home, their belongings, their family and friends; to disrupt any plans they might have made; hell, even to remove from them their basic ability to make decisions for themselves. A reason to effectively imprison them against their will, with their freedom vague and nebulous, hinged upon convincing their captor of their essential harmlessness. Of their submissiveness.

So, do you find it to be acceptable to remove a person from their life and subject them to indignities, based on a hunch, a feeling, something spoken at some time in their past? What else is a good reason then? And how long is permissible? Even if the detention is temporary; just how long is temporary? 5 weeks? 6? more? How long is too long? How long is enough? It seems, at least to me, to be far too easy to make a decision like this when it's not your life being impacted; no, someone else gets to bear the burden. Someone else doesn't get to go home that night. Someone else has to sleep in an unfamiliar place, surrounded by strangers, while the person who put them there gets to continue life as usual. I suppose that makes justifying such an act easy, since there is so little personal impact.

So, in this case, it was ruled that there was no sufficient cause for the intervention; for criminal treatment (and being 'escorted' by the police to a secure facility where you are held against your will is no different than being arrested - remember, "A rose by any other name"..); yet you still search for some justification for this action. Because a psychiatrist initiated it? Is it not possible that he could be wrong? The court certainly seemed to think so..

Ultimately, a woman lost 51/2 weeks of her autonomy, her decision-making ability, her freedom,; hell, her life - without cause. And that's OK with you? Because, well, I don't know - please explain it to me. Why is it so important to deny an individual his or her freedoms based on nothing more than ephemera; hunches and guesses; A feeling? clearly, there is a great potential for error; as this case shows. Yet the response is, 'well, there must be a reason'? That's all?

P.S. Isn't it interesting that the psychiatrists posting here seem just fine with imprisoning someone on the barest of excuses, ones that do not hold up under legal scrutiny? As if it is nothing more than a small vacation, and not an imposition on the very fundamental nature of individuality? That there must be more to the story, even though the Judge decided that that the 'more' was not enough?

"ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment. Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up."

Does that sound familiar? It should, it's copied from your site - Reidbord's Reflections - and posted there by you not long ago.The details of this case, however, appear to repudiate your claim. You can, in fact, be committed for divulging such thoughts. The risk is real, and in this case, became a reality.

You have an interesting view of the legal system. Yes, it is structured with appeals, but that system is designed as a system of fail-safes, not as an excuse to "shoot 'em all and let God sort 'em out". In other words, instead of a process that allows such routine errors at the basic level, utilizing an appeals process as a sort of legal strainer to catch the legitimate cases while discarding the mistakes, we have a system that emphasizes minimal errors to begin with, with appeals in place as a secondary, and sometimes tertiary (or more) oversight process. The difference is that with your view of the system everyone is at risk, as mistakes are acceptable at the initial stage, since the process will sort it out later; while the actual system attempts (admittedly poorly at times) to avoid those errors in the first place. As far as a miscarriage of justice - yes, it is one, which is why it was judged to be an illegal detainment. She was in essence 'punished' for a 'crime' that she did not commit. The appeals system is there to rectify such injustices, not to separate the wheat from the chaff.

@je suis: "The details of this case, however, appear to repudiate your claim. You can, in fact, be committed for divulging such thoughts."

I seem to recall reading that she divulged an intent to suicide if anything happened to her kids. An intent to act is very different than the "sharing ideas or feelings" you quoted from my site. A similar distinction would be talking about the joy one feels in imagining someone dead, versus divulging a plan to actually kill the person.

Even given her prior statement about suicide, I may or may not have applied a legal hold myself. As I said, I wasn't there and don't know the details. Certainly a person can make such a declaration in haste and later recant it.

Conscientious psychiatrists do not apply holds willy-nilly and let the courts sort them out. As you read on my blog, I do believe "better safe than sorry" commitments happen too often, and I caution trainees and colleagues to take this weighty responsibility seriously. Even when we do, reasonable people will disagree about specific cases. Thus the court will overturn some commitments upon review, without implying anything about the competence or good will of those who applied it in the first place.

And really, Je Suis, since you oppose involuntary commitment on principle, why worry yourself over such details? You would still oppose it even if this woman had clearly intended to commit suicide, and even if the court had upheld the hold. As Dinah said — and you agreed — that says it all.

I'll agree that there may be more to the stories, but the part that I have a hard time understanding is why some physicians cannot recognize when they are making a situation worse and stop doing that. If a patient is getting worse and worse with the treatment being provided, then why not step back and say, maybe what I'm doing is not helpful with this patient. Maybe the patient needs a kinder, gentler approach. That just doesn't seem to happen with involuntary treatment.

An intent to act is not very different from an idea or a feeling, actually - it is, in fact, an idea, most likely based upon a feeling, with a planned resolution. Until that resolution is enacted, it remains an idea. The entirety of the issue is intent, then. And that's where the problem lies - a Judge ruled that the information divulged, whether intent or idea, was not sufficient cause. Period. No "well, there might have been more to the story" - that has no bearing any longer. This was not a legal hold; it's really that simple. She was held captive for 51/2 weeks for divulging a thought, or an intent, neither of which met the legal criteria necessary for such an enormous intrusion on her life. Yet posts here still question the decision made by the judge, asserting that there must be more? That sounds a lot like "she must have done something to bring this upon herself", a kind of blame the victim mentality; or a final attempt at a justification of sorts.

Since I oppose involuntary commitment on principal, why worry over such details? Well, this whole case is exactly why. It shows an authority that is too easily abused, with little to no consequences. It violates the basic tenants of this country, i.e. life, liberty, the pursuit of happiness. In a single moment, based on a whim, a hunch, a feeling, an individual stands to lose - even if temporarily - their freedom of association, their chosen surroundings, their access to family and friends, their possessions (life), their freedom (liberty) and their volition (the pursuit of happiness). This loss of the basic foundations of our society, the ideals that the country is founded upon, seems to be treated far too lightly. Sure, a judge released her, but only after being held well over a month, and only after she managed to bring attention to her plight herself. Where was all the people who were supposed to be helping her? They were too busy denying her her basic rights, and wrongfully - according to a judge, the expert in the legality of the matter. So, now how does she regain what was taken? Simple, she cannot. It's gone for good. Taken in the name of 'help'. Of 'altruism'. Of 'concern'. It appears that that concern is very much limited in scope.

I have mentioned this before, but I will repeat it here - I work/have worked in healthcare. This case does not surprise me at all; I have seen firsthand much more flagrant violations of the ability to initiate these holds. It happened, it is still happening, and it will continue to happen. The process is rife with abuse, misunderstandings, or outright ignorance. The problem is that the target of these holds pays the price, while the perpetrator walks away untouched. It's too easy. Way, way too easy - and cases like this are the result.Because, well, there must be something more, a good reason; she must have brought this upon herself. Of course there must be. Even when there isn't.

@P-K: " I have a hard time understanding ... why some physicians cannot recognize when they are making a situation worse and stop doing that.... That just doesn't seem to happen with involuntary treatment."

Physicians are fallible. Like politicians, lawyers, salesclerks, manufacturers, and just about everyone else, we make mistakes, have blind spots, sometimes fail to do what we should and sometimes act when we shouldn't. The stakes are high, and physicians, including psychiatrists, should be held to a very high standard. But since we're human, perfection isn't a reasonable expectation.

I have seen a number of situations involving involuntary treatment where physicians recognize they are making the situation worse and stop doing what they're doing. No protest from me if you want to argue this doesn't happen nearly often enough.

@je suis: While intent is a type of feeling, the distinction is clear in the law. You can say or write that the US would be better off with a Fascist dictator, but if you (believably) declare an intent to establish one, your liberty will be sacrificed for the public good. Likewise, you are free to express that we'd be better off without a specific ethnic group, or people over 60, or sexual minorities, but you will be arrested if you show a believable intent to take action. The dangerousness standard for involuntary commitment uses the same logic, and even the same standard of evidence ("probable cause") that allows police to arrest a suspect for _intending_ to commit a dangerous act.

You write that this process "is rife with abuse, misunderstandings, or outright ignorance." We can quibble over how "rife" these are, but we essentially concur if you recognize the value of such holds in some situations, and also that abuse, misunderstandings, and ignorance are scourges of the human condition, and should be countered whenever possible. It is only when you argue that such holds are evil in principle that we disagree. I wonder if you saw this "60 Minutes" segment.

Again, you may have the last word if you wish — a courtesy, not a "dominion" for pete's sake.

"Physicians are fallible. Like politicians, lawyers, salesclerks, manufacturers, and just about everyone else, we make mistakes, have blind spots, sometimes fail to do what we should and sometimes act when we shouldn't."

I understand making a mistake. I had a nurse once give me someone else's medication, and I took the drug. The nurse said he was sorry. I accepted his apology. What the psychiatrists in these situations are doing is not a mistake. They are choosing to be blind.

Is there anything this woman could have done to make it any more clear to the mental health professionals that they were making a very bad decision? If they didn't notice it immediately, how did they fail to notice they were harming her day after day after day, for 5.5 weeks? I listened to her speech and I have no doubt she was crystal clear with the psychiatrist that he/she was making things worse. Continuing to do what they did is not a mistake, they chose to continue to do harm. I have no tolerance for that.

I am glad to hear that you know of situations where the psychiatrist realized they had made a mistake with involuntary treatment. That gives me a wee bit of hope. I fear, though, that there is so much defensiveness around this topic that mental health professionals more often than not are unable (or unwilling) to put this defensiveness aside and recognize when involuntary treatment is not helping a particular patient. The running joke when I was inpatient was if you want out pretend like you want to stay, and if you want to stay pretend like you want to go home. It shouldn't be like that.

Maybe some good will come from this in Vermont. The public is overwhelmingly in support of her, at least from the comments in the newspaper. Maybe Vermont laws will be changed to make it harder to do to people what they did to her. I hope so.

The moral of the story is to choose your mental health care professionals wisely. Have these discussions about hospitalization and if you don't like their answer, get out while you can. I have no doubt whatsoever that my therapist and psychiatrist would have done things very differently, and I wouldn't see them if I thought otherwise.

@P-K: "What the psychiatrists in these situations are doing is not a mistake. They are choosing to be blind."

Which situations? All involuntary holds? The Vermont woman specifically? Because the latter is an atypical case for several reasons.

"Is there anything this woman could have done to make it any more clear to the mental health professionals that they were making a very bad decision? [...] I listened to her speech and I have no doubt she was crystal clear with the psychiatrist that he/she was making things worse."

I just listened to her speech too, and did a little more reading about the case. Apparently Vermont is the only state that lacks a "probable cause hearing" as part of the commitment process. It also relies on a judge's finding of "clear and convincing evidence" of danger, a higher-than-usual evidentiary standard, to commit. These two facts alone make it hard to draw general conclusions from her case. In other states her hold may have been overturned at a mandatory hearing within the first week; conversely, the "clear and convincing" standard in Vermont may lead a reviewing judge (eventually) to deny or overturn commitments that would have been upheld in other states.

The one thing that was clear from her speech is how vehemently she disagreed with being hospitalized. Was her commitment a very bad decision? Did it make things worse? Those are different questions, and I don't claim to know the answer. Her family, not just the doctors, wanted her committed. She had previously threatened suicide if her children were harmed, and one was just killed. Neither of these settles the matter of course, but it makes me curious. What's the other side of this story? In the end, as much as news stories provide fodder for online commentary, we readers simply don't have sufficient facts to reach conclusions about the decisions made. The one conclusion I reach regarding this woman is that Vermont badly needs to revise its laws, so that psychiatric holds trigger an automatic judicial review early in the process.

"The moral of the story is to choose your mental health care professionals wisely."

""Is there anything this woman could have done to make it any more clear to the mental health professionals that they were making a very bad decision? If they didn't notice it immediately, how did they fail to notice they were harming her day after day after day, for 5.5 weeks? I listened to her speech and I have no doubt she was crystal clear with the psychiatrist that he/she was making things worse. Continuing to do what they did is not a mistake, they chose to continue to do harm. I have no tolerance for that. ""

That is the crux of the situation P-K. And when we protest this, due to our "mental illness" label, we don't know what we are talking about and are simply delusional. Heck, regular doctors act this way too but it is alot worse with many psychiatrists

I read the other details also, and it just doesn't change things for me. It's so lacking in human decency to respond to someone who has suffered such a tragedy with handcuffs, instead of putting their arms around her. It's sick.

I wish so much that she could have had the kind of response I received from my therapist when I was in trouble. My therapist didn't wait until I showed up for an appointment and then meet me with handcuffs. She didn't have me dragged off to the psych ward. She cancelled her appointments and came to my home. She put her arms around me and walked my dog. She could have called the police, she had grounds to do to me what they did to that woman. She didn't do it, though. She put herself in my shoes. We need more therapists like her.

I think the story resonates with me so much, because things could have been handled in a way that actually helped her rather than leaving her with additional pain and anguish. It's not right what they did to her, even if they were well intended. They screwed up. It also concerns me that their actions may cause people to avoid care out of fear that the same will be done to them, and that would be a double tragedy.

@AA: No one in this discussion is delusional. Yes, the video was heartbreaking. We still don't know what she was like 6 weeks prior. I'm more than willing to have the offending shrink nailed to the wall if facts (not speculation) surface that he acted unethically, illegally, or committed malpractice.

@P-K: Your therapist sounds extraordinary, and I'm glad she helped you in ways very few therapists would. Given all our discussion here about fallible, ignorant, boneheaded (etc) mental health professionals, it's important to realize that those who work unconventionally — canceling other patients, coming to your home, etc — may bring additional risks as well as benefits. I've seen well-meaning, humane, "we're all God's creatures" therapists unwittingly enter dual relationships with patients, send mixed signals, cross important boundaries, and paint themselves into therapeutic corners. If your therapist is thoughtful and sensitive enough to act as she did with you and still avoid these pitfalls, then you indeed chose your therapist wisely.

Dr. Reidbord, I was talking in general terms when I made the point that people with MI labels generally are not given credibility by psychiatry. I have mentioned this point before but it bears repeating.

I know someone who had been very compliant about taking medication with nasty side effects. But when this person complained to her psychiatrist that the one she was currently taking was causing stomach upset. He refused to listen and blamed everything on her mental illness. When she became admittedly belligerent due to being frustrated that he diminished her complaints in that manner, he called the cops and had her committed.

In my opinion, from what I have read, that type of situation happens frequently as unfortunately, many of your colleagues go on power trips instead of listening to their patient. Of course, as you say, no one knows exactly what happened in the case of Christina Schumaker.

But anyone who seems predetermined to admit someone to a psych hospital the day after that person experiences a tragedy that no one should experience, seems pretty power hungry to me.

By the way, I do appreciate the way that people with past and current psych med histories are treated on this blog with respect. Unfortunately, I don't feel that extends to many of your colleagues.

And to be fair, many non psychiatrists act that way also towards patients with psych med histories. A whole other topic.

Dr. Reidbord, you may no longer be reading this post, but be assured there was no dual relationship with my therapist. It was a one time deal, an emergency situation, and it was professional and appropriate. In fact, I've graduated from therapy, so there was no dependency created. She is truly extraordinary.

My psychiatrist would not have responded in the same way, nor would I have wanted him to, but he would still have done things right. His response when concerned is to increase frequency of contact, and to say "call if you need me." (I've called him a grand total of once).

One thing she said that really struck me was that in the hospital she was all alone. I felt the same way she did when I was hospitalized. I felt alone and unheard, and I left there feeling like I couldn't turn to anyone lest they do this again. It's good to find mental health professionals who handle things in a way which actually leads to healing, rather than causing more harm. I think that's one thing my therapist and psychiatrist have both done really well, they made sure I was not alone in my darkness.